Best practice is to autopsy all overdose deaths

Based on national standards, a single forensic pathologist is allowed to perform up to 300 autopsies per year.

Based on national standards, a single forensic pathologist is allowed to perform up to 300 autopsies per year.

Various tubes in the morgue at the New Hampshire Office of the Chief Medical Examiner are used to collect toxicology specimens.

Various tubes in the morgue at the New Hampshire Office of the Chief Medical Examiner are used to collect toxicology specimens. Hadley Barndollar photos / New Hampshire Bulletin

This chart shows the breakdown of types of deaths investigated by the Office of the Chief Medical Examiner in 2020. (Screenshot)

This chart shows the breakdown of types of deaths investigated by the Office of the Chief Medical Examiner in 2020. (Screenshot) —Screenshot

By HADLEY BARNDOLLAR

New Hampshire Bulletin

Published: 11-16-2023 3:02 PM

It’s the position of the National Association of Medical Examiners that all overdose deaths should be autopsied. Specifically, the organization says that “external examination is an inadequate substitute for autopsy for the purposes of detecting and certifying drug-caused deaths.”

But due to staffing shortages plaguing medical examiner offices nationwide, that’s not happening in New Hampshire. In fact, data shows that out of close to 300 deaths considered drug-related so far in 2023, 140 were autopsied while the other 157 received external exams only. That’s more than 50 percent of drug deaths that have gone without an autopsy this year. 

While toxicology tests are performed on all overdose deaths, showing which drugs were present in the person’s system and at what quantity, an autopsy provides the most comprehensive and accurate look at the cause of death, which isn’t always obvious, experts say.

On a recent Friday morning, Kim Fallon, chief forensic investigator for the New Hampshire Office of the Chief Medical Examiner, descended three flights of stairs into the basement of Concord Hospital. She opened an unmarked door — the morgue, where bodies are stored in a large freezer, on racks and on the floor, and signs about formaldehyde plaster the walls.

On a whiteboard in the chilled room where autopsies are performed, written in dry-erase marker, are words such as “liver,” “thymus,” and “femoral.” Scales suspended in the air are used to weigh individual organs. Countless tubes labeled with various colors are reserved for blood, urine, and vitreous fluid.

Fallon said the National Association of Medical Examiners, which grants accreditation to offices like hers, has standards for how many autopsies a forensic pathologist can perform per year. Ideal is 250, she said, and the number shouldn’t go over 300.

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With just two forensic pathologists in New Hampshire’s office – Drs. Jennie Duval and Mitchell Weinberg – that means no more than 600 total autopsies for an entire year. 

Drug deaths are only one kind of case the Office of the Chief Medical Examiner handles. Under state law, it has jurisdiction over sudden, unexpected, or unnatural deaths, including homicides, suicides, unintentional injuries, car crashes, and others. 

“If we had 500 overdose deaths a year, that’s all we would be doing and no one else would be getting autopsied,” Fallon said.

In 2020, for example, according to the office’s annual report, the breakdown was as follows: Of 1,749 deaths investigated, 52 percent were fatal accidents (which includes unintentional overdoses), 32 percent were natural deaths, and 13 percent were suicides. Around 1 percent were ruled homicides and 2 percent were undetermined. The office conducted 587 autopsies that year.

New Hampshire isn’t alone in the predicament of having to choose which individuals they autopsy. There is a critical shortage of forensic pathologists nationwide. According to the national association, it’s estimated the country has just 750 full-time, board-certified forensic pathologists. Some estimates say the U.S. needs 1,200 to 1,500 to meet the demand. 

The only way to hire a forensic pathologist, Fallon said, is to poach one from another office or wait for the new class to pass their board exams each academic year. Per the College of American Pathologists, an average of 37 new forensic pathologists have been certified per year over the last 10 years, but surveys indicate that only 21 full-time newly trained individuals remain in the field each year.

Becoming a forensic pathologist requires a minimum of 13 years of schooling. After obtaining an undergraduate degree, candidates must complete medical school to become a licensed M.D., followed by a four-year residency in anatomic and clinical pathology, and then an additional year of a forensic pathology residency or fellowship. Only then are candidates allowed to take their board exams, making them eligible to enter the career field.

In New England, there are two fellowship training sites, in Boston and Farmington, Connecticut.

In 2021, trying to fill a vacancy for an associate medical examiner, New Hampshire’s job listing indicated a salary range of $200,000 to $240,000.

“We have the OK to hire a third pathologist, you just can’t get one,” Fallon said. “There are plans with somebody who would be finishing up schooling next year.”

Based on national standards, New Hampshire’s office should have three forensic pathologists. Lately they’re utilizing locum tenens, or temporary contractors, in an attempt to make up for the vacancy. 

Why should drug deaths be autopsied?

In an overdose death scenario, it’s typical that most individuals die at the scene. Assistant deputy medical examiners, who are on call 24/7 in all 10 counties, will arrive and conduct their own investigation alongside police.

If the decision is made to forgo an autopsy, the body will typically be transported to a funeral home, where the ADMEs perform an external exam – looking for puncture wounds or track marks, for example, along with drawing specimens for toxicology. The death isn’t certified as an overdose until the toxicology report comes in, which can take around eight weeks, and a doctor reviews it.

In some cases, that may be sufficient, but it’s not considered best practice, said Fallon.

“An autopsy is looking at every organ individually and seeing if they had any heart problems, an infection, any abnormalities,” she said. 

Toxicology results may reveal that someone very likely died of fentanyl intoxication, for example, but they won’t show if they had endocarditis or a brain abscess, common conditions in chronic drug users. 

“People can die from other things while they’re overdosing on drugs,” Fallon said. “You could miss something.”

Why is an accurate cause of death so important? Death certifications have public health and data collection implications. The cause of death can also be critical for families and loved ones, for historical documentation, and for financial reasons, as well. For deaths certified as COVID-caused, for example, families were eligible for up to $9,000 through FEMA’s COVID-19 funeral assistance program. 

The autopsy crunch wasn’t always so dire. Prior to the opioid crisis, there used to be fewer than 200 drug deaths a year in New Hampshire and all of them would be autopsied. 

The same has happened in other states. According to a 2018 Department of Justice report, on average, medical examiner offices nationwide were performing autopsies in just 38 percent of deaths investigated.

David Fowler, who retired as Maryland’s chief medical examiner in 2019, published a 2017 study looking at skyrocketing overdose deaths, staffing shortages, and fear of losing accreditation if doctors perform more autopsies than they’re allowed. In his conclusion, he wrote, “Now, more than at any other time, accurate certification of deaths from a cause that is a major threat to the public’s health is critical. These data inform so many potential interventions and also act as an important tool in the evaluation of these interventions.”

Fowler said that “not fully investigating these deaths with a full autopsy to properly evaluate them completely threatens the intent of a competent medicolegal death investigation system.”

Similarly, the National Association of Medical Examiners says a complete autopsy is necessary for “optimal interpretation” of toxicology results, and should be considered in conjunction with scene findings, medical history, and circumstances surrounding the death. 

“When we get a third doctor, we’ll be doing more autopsies,” Fallon said.